Investigation: Are talking therapies working?

The Improving Access to Psychological Therapies (IAPT) programme is entering some choppy waters.

Despite thousands of patients being moved off sick pay and benefits, and recovery rates approaching 50%, some experts are calling for a rethink of the Government’s flagship programme for patients with mental health problems.

A Pulse investigation has revealed that access to psychological therapies is patchy across England, with long waiting times and stark differences in the resources CCGs are allocating to the programme.

Recent evidence on the cost-effectiveness of IAPT has also raised questions, with the cost per QALY approaching NICE’s upper threshold of £30,000. Is it time for a re-evaluation of the scheme?

Variation in funding

Launched in 2007, IAPT sought to cut waiting times for appropriate, NICE-recommended psychological therapies for depression and anxiety. Economists argued the programme could save £1bn a year by 2016 through helping people off welfare and into work. The coalition Government expanded the scheme, launching a four-year plan in 2011 to extend psychological therapies to more patient groups, including children and young people, patients with severe mental illness and those with medically unexplained symptoms.

I don’t know if there is a problem with IAPT itself, but there are broader issues in the evaluation of it

Professor Paul McCrone

But three-quarters of the way through this programme, progress has been mixed, according to figures collated by Pulse under the Freedom of Information Act. Among the 85 CCGs able to provide information, there is wide variation in the funding allocated to IAPT for this financial year, from £1.76 to £14.55 per head of population.

Around a third (32%) of the CCGs report average waiting times within the IAPT key performance indicator of less than 28 days, while most have much longer waiting times for high-intensity forms of therapy (step 3 or higher of the IAPT stepped care pathway) – typically around three to four months, with some as long as 12 months.

Only 10 of the 85 CCGs have IAPT services in place for under-18s, although NHS England insists this figure does not take into account the expansion of existing local Child and Adolescent Mental Health Services under the IAPT programme.

An interim report published by the Department of Health in November 2012 claimed IAPT had largely met and in some cases exceeded expectations, with recovery rates approaching the target of 50% of treated patients and more than 45,000 patients moved off sick pay and benefits.

But data from the Health and Social Care Information Centre (HSCIC) for January to March 2013 showed a wide variation in recovery rates, from 23% in Hull to 83% in North Lincolnshire. Drop-out rates remain high – with just under 60% of referred patients receiving any treatment and less than two-thirds of those who did enter treatment completing at least two sessions.

The HSCIC also revealed services are slipping behind the target of reaching 15% of the population in need each year, with just 2.5% of eligible patients seen in the final quarter of 2012–2013.

Cost-effectiveness concerns

The latest published evidence on cost-effectiveness compared IAPT at one of the original pilot sites in Doncaster with two local sites in Wakefield and Barnsley offering usual services for common mental illness over eight months. It found IAPT patients did not have statistically significant reductions in depression and anxiety scores compared with those receiving usual care. A similar proportion – around a fifth – of patients in each group achieved reliable improvement.

The HSCIC estimated the cost of IAPT per QALY gained at £29,500; NICE uses a threshold of £20,000 to £30,000.

Professor Paul McCrone, professor of health economics and director of the centre for the economics of mental and physical health at King’s College London, says the findings suggested IAPT is ‘probably not cost-effective’.

He adds: ‘The evidence is still emerging and I don’t know if there is a problem with IAPT itself, but there are broader issues in the evaluation of it and we do need to be cautious about the results.’

He adds: ‘I think when you base a policy on its impact on something like employment, you sometimes have to adapt your thoughts according to the economic climate.’

Consultant psychiatrist Dr David Christmas, from Ninewells Hospital and Medical School in Dundee, is particularly sceptical about IAPT, which he says has prompted psychological therapies to become ‘over-generalised’ to treat all severities and forms of depression, including some where the benefits are less certain.

He says: ‘It is reminiscent of Abraham Maslow’s quote that “it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail”.’

Dr Christmas says: ‘Most people going into IAPT are economically active and do not resemble the types of depressed patients most GPs see. We know these interventions likely offer little to patients, for example those with chronic depression, that GPs are struggling with. The problem is IAPT is the only game in town.’

CBT doesn’t suit everyone

Professor Tony Kendrick

Professor Tony Kendrick, professor of primary care at the University of Southampton, is more positive, but agrees the economic impact of IAPT could be limited.

Professor Kendrick says: ‘In practice it may well be it doesn’t pay for itself – partly because, although it’s effective in those who actually have the treatment, a lot of people referred only go for the assessment. They don’t go on or they drop out. A lot of therapists’ time may be spent on people who don’t engage with it.’

In addition to high drop-out rates, he points out that IAPT is not being accessed by the majority of patients who in theory could benefit – for example, only 6% of patients with a registered common mental health problem were referred for IAPT in the demonstration studies.

He says: ‘CBT doesn’t suit everyone; it requires patients to put an effort in, do homework between sessions and engage cognitively, and some people are either too depressed to be able to concentrate or may not be used to verbal reasoning.’